Healthcare Provider Details

I. General information

NPI: 1790608990
Provider Name (Legal Business Name): ATAMI DE MAIN PHD, AGPCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4539 N 22ND ST STE N
PHOENIX AZ
85016-4639
US

IV. Provider business mailing address

4539 N 22ND ST STE N
PHOENIX AZ
85016-4639
US

V. Phone/Fax

Practice location:
  • Phone: 928-393-9364
  • Fax:
Mailing address:
  • Phone: 928-393-9364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number241164
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number241164
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number241164
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: